The Effects of Patient Support on Treatment Adherence and Treatment Outcome. Susan van den Hof Liverpool, 28 Oct 2016

Transcription

1 The Effects of Patient Support on Treatment Adherence and Treatment Outcome Susan van den Hof Liverpool, 28 Oct 2016

2 Conflict of interest disclosure I have no, real or perceived, direct or indirect conflicts of interest that relate to this presentation. I have the following, real or perceived direct or indirect conflicts of interest that relate to this presentation: Affiliation / financial interest Tobacco-industry and tobacco corporate affiliate related conflict of interest Grants/research support (to myself, my institution or department): Honoraria or consultation fees: Nature of conflict / commercial company name Participation in a company sponsored bureau: Stock shareholder: Spouse/partner: Other support or other potential conflict of interest: This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker s interests or relationships may influence the presentation. Drug or device advertisement is strictly forbidden.

3 Background Reasons for incomplete treatment adherence Long treatment duration Quick improvement of symptoms early in treatment Adverse drug reactions Financial burden Stigma Social support interventions (SSI) are being provided by several TB programs to remove or alleviate barriers to treatment adherence There is uncertainty about the contribution of SSI on treatment adherence and treatment outcomes

4 Systematic literature review To identify SSI provided to (MDR) TB patients To assess the effects of these SSI on treatment adherence and treatment outcomes

5 Methods: interventions and outcomes Two categories of SSI: Psycho-emotional (PE) support: emotional support through psychological interventions; Socio-economic (SE) support: tangible support through interventions delivering services, material goods, financial assistance Outcome measures: Treatment adherence Treatment outcomes Financial burden hardly any data available

6 Methods: Literature review Medline/Pubmed and Embase: Jan Feb Abstract book of World Conferences of Lung Health (2010-3) Language restricted to English, German, French, Portugese, Russian, Spanish Eligibility criteria (MDR) TB patients Ambulatory care Description of intervention Assessment on adherence, treatment outcomes or financial burden Comparison of an intervention group and no support group

7 Number of identified studies 1752 abstracts 25 studies described 21 studies in meta-analysis

8 Counseling Self-help groups Stigma reduction Psychotherapy Involvement of a treatment supporter Home visits Other psycho-emotional support Food supplementation Other material support Direct economic support Indirect economic support Included in quantitative SSI studies 11 Randomized Clinical Trials 14 Non-Randomized Studies 3 in LIC 16 in MIC 6 in HIC Most data from Brazil, China, Russia, South Africa and Senegal 11 SE support 7 PE support 7 SE & PE support 46 to 4,091 participants per study PSYCHO-EMOTIONAL SUPPORT SOCIO-ECONOMIC SUPPORT Non-Randomized Studies Bock et al [20] Cantalice Filho 2009 [45] Davidson et al [56] Farmer et al [57] Finlay et al [53] Garden et al [54] Gelmanova et al [66] Jakubowiak et al [44] Lu et al [48] Macq et al [59] Soares et al [68] Sripad et al [62] Wei et al [63] Zou et al [64] Randomized Controlled Trials Alvarez et al [50] Baral et al.2014 [52] Drabo et al [67] Jahnavi & Sudha 2010 [58] Janmeja et al [55] Liefooghe et al [46] Lutge et al [47] Martins et al [60] Morisky et al [61] Sudarsanam et al [49] Thiam et al. 2007

9 Effects SSI on treatment success PE, SE and PE&SE support led to higher treatment success

10 Effects SSI on unsuccessful treatment outcomes PE, SE and PE&SE support led to less unsuccessful outcomes

11 Effects SSI on treatment adherence Three RCTs assessed the effect of PE and/or SE on treatment adherence PE in Mexico (self-help groups): significant improvement (RR 1.20; CI ) SE in USA (subway tokens): no significant improvement (RR 1.11; CI ) SE in Timor-Leste (nutritional support): no significant improvement (RR 1.01; CI )

12 WHO systematic review: Social support interventions 13

13 Material support: (food, financial incentive or transport/living subsidy) Outcome Study design Number of studies RR (95% CI) Success RCT ( ) Success Observational ( ) Mortality Observational ( ) Failure RCT ( ) Loss to follow up RCT ( ) Higher rate of treatment success and sputum conversion Lower rate of mortality, treatment failure, and loss to follow up in patients with material support interventions

14 Patient education and counseling Outcome Study design Number of studies RR (95% CI) Success RCT ( ) Completion RCT ( ) Cure RCT ( ) Adherence RCT ( ) Loss to follow up RCT ( ) Higher rates of treatment success, completion, cure and adherence in patients provided with patient education & counseling

15 Psychological support Outcome Study design Number of studies RR (95% CI) Success RCT ( ) Completion RCT ( ) Completion Observational ( ) Failure RCT 1 Risk difference (-0.22, 0.01) Loss to follow up Observational ( ) Loss to follow up RCT ( ) Higher rate of treatment completion; Lower rate of treatment failure and loss to follow up with psychological support

16 Discussion and conclusion Psycho-emotional and/or socio-economic support interventions improve treatment outcomes Little evidence on effects on treatment adherence and financial burden Most support included multifaceted types of interventions, so no conclusions can be drawn on the effect of individual interventions But multifaceted types of interventions may be needed Well-designed studies would provide more certainty on the effects of different PE and SE interventions More systematic data collection by TB programs to monitor implementation and evaluate effects also needed Reports should include information on costs and sustainability to provide information on efficiency and scalability

17 Thank you! Acknowledgments KNCV Rosa van Hoorn Agnes Gebhard WHO Ernesto Jaramillo Linh Nguyen MSH David Collins